My elderly patient developed a new left bundle branch block following transcatheter aortic valve replacement. Is this a frequent occurrence?

Yes, conduction abnormalities, particularly left bundle branch block (LBBB), frequently complicate transcatheter aortic valve replacement (TAVR).

A 2016 systematic review and meta-analysis reported new-onset LBBB following TAVR and persisting at hospital discharge in 13.3%-37% of patients1; the incidence may be higher or lower depending on the type of prosthesis used.2,3 In the same systematic review, new-onset LBBB was associated with a higher risk of permanent pacemaker placement (PPI) and cardiac death during 1-year followup.   In another study, persistence of LBBB post-TAVR without PPM placement was associated with an increased risk of syncope, complete AV node block, and PPI, but not overall mortality.4

The underlying anatomy of the conduction system may help explain post-TAVR conduction complications. The AV node is located adjacent to the membranous septum, closely associated with the subaortic region and LV outflow track, giving rise to the LBB.5 Protrusion of TAVR prostheses into the LV outflow tract, the mechanical injury occurring during the predilation or the positioning of the valve, and potential trauma to the conduction system by the catheters and guidewires used in TAVR may all contribute to these complications.3,5

References

  1. Regueiro A, Altisent OA, Del Trigo M, et al. Impact of new-onset left bundle branch block and periprocedural permanent pacemaker implanation on clinical outomces in patients undergoing transcatheter aortic valve replacement: A systematic review and meta-analysis. Circ Cardiovasc Interv 2016;9:e003635. http://circinterventions.ahajournals.org/content/9/5/e003635.long
  2. Nazif, T.M., Williams, M.R., Hahn, R.T., Kapadia, S., Babaliaros, V. et al. Clinical implications of new-onset left bundle branch block after transcatheter aortic valve replacement: analysis of the PARTNER experience. Eur. Heart J. 2014;21:1599-1607. https://www.ncbi.nlm.nih.gov/pubmed/24179072
  3. Bourantas CV, Serruys PW. Evolution of transcatheter aortic valve replacement. Circ Res 2014;114:1037-1051. http://circres.ahajournals.org/content/114/6/1037
  4. Urena, M., Mok, M., Serra, V., Dumont, E., Nombela-Franco, L. et al. Predictive factors and long-term clinical consequences of persistent left bundle branch block following transcatheter aortic valve implantation with a balloon-expandable valve. J Am Coll Cardiol. 2012;60:1743-1752. https://www.ncbi.nlm.nih.gov/pubmed/23040577
  5. Piazza, N., Jaegere, P., Schultz, C., Becker, A.E., Serruys, P.W., Anderson, R.H. Anatomy of the aortic valve complex and its implications for transcatheter implantation of the aortic valve. Circ Cardiovasc Interv. 2008;1:74-81. https://www.ncbi.nlm.nih.gov/pubmed/20031657

Contributed by Salvatore D’Amato MD, Mass General Hospital, Boston, MA

My elderly patient developed a new left bundle branch block following transcatheter aortic valve replacement. Is this a frequent occurrence?

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